Dispositions Re Euthanasia Among Dutch Physicians: An Interpretation (part 4)
4. The ‘bar keeper’ disposition
4.1 Summary: Physicians with this disposition are predisposed to consider managing a patient’s death by euthanasia when the patient is convinced his/her suffering is unbearable and when they are convinced the patient is competent to make this request.
4.2 Metaphor: The bar keeper is responsible for insuring that individuals ordering alcoholic drinks (1) are of legal age and (2) do not so compromise their competency to the point that s/he or others are put at risk.
4.3 Commentary: No Dutch physician in this study represents this disposition. However, the Dutch professional and public literature I have reviewed suggests that some Dutch physicians practice with this disposition. They would all acknowledge that they cross the threshold from ‘managing life/recovery’ to ‘managing death/dying process’ with some patients. For them, such patients would most often be patients whose suffering is associated with a somatic condition. However, they need not be so classified. The patient’s assessment of the magnitude of the suffering is the decisive factor in crossing the threshold from ‘managing life/recovery’ to ‘managing death/dying process’. In contrast to physicians with ‘backed against the wall’ or ‘peripheral vision’ dispositions, these physicians do not form a judgment about or seek agreement with the patient about the criteria by which to conclude that the suffering is unbearable. Instead, these physicians accept the patient’s assessment, regarding the matter to be too subjective to do otherwise. The question for which they accept responsibility is the competency of the patient who is persistently requesting euthanasia. These physicians are prepared to provide euthanasia to competent patients. They would agree to provide euthanasia for all patients for whom physicians with ‘backed against the wall’ or ‘peripheral vision’ dispositions would provide euthanasia. They also would consider not providing euthanasia in cases in which they are convinced the patient is not competent. They do not experience the level of moral dissonance in agreeing to perform euthanasia common among physicians with ‘back against the wall’ or ‘peripheral vision’ dispositions. Though not often politically active themselves, these physicians hold a disposition toward euthanasia that corresponds most closely with one or more of the parties that have comprised the governing coalition since 1995. Physicians with a ‘bar keeper’ disposition toward euthanasia support efforts to legalize this practice.
4.4 Distribution: Among the Dutch physicians in this study, none have identified themselves with this disposition. The more removed their dispositions are from the ‘bar keeper’ disposition, the more certain they tend to be that the end-of-life management of as many as 20% of current Dutch physicians corresponds most closely with the ‘bar keeper’ disposition. It is my impression that as early as 1973 few (if any) Dutch physicians held a ‘bar keeper’ disposition. By 1984 perhaps a small number of Dutch physicians had concluded that a patient’s ‘quality of life’ is too subjective for physicians to question a patient’s conclusion that their suffering is not bearable and were, thus, prepared to provide euthanasia to patients unless uncertain about their competency. By 1993 it is my impression that the percentage had grown to perhaps 5-10% of Dutch physicians. This percentage seems to have remained constant to the present time.
4.1 Summary: Physicians with this disposition are predisposed to consider managing a patient’s death by euthanasia when the patient is convinced his/her suffering is unbearable and when they are convinced the patient is competent to make this request.
4.2 Metaphor: The bar keeper is responsible for insuring that individuals ordering alcoholic drinks (1) are of legal age and (2) do not so compromise their competency to the point that s/he or others are put at risk.
4.3 Commentary: No Dutch physician in this study represents this disposition. However, the Dutch professional and public literature I have reviewed suggests that some Dutch physicians practice with this disposition. They would all acknowledge that they cross the threshold from ‘managing life/recovery’ to ‘managing death/dying process’ with some patients. For them, such patients would most often be patients whose suffering is associated with a somatic condition. However, they need not be so classified. The patient’s assessment of the magnitude of the suffering is the decisive factor in crossing the threshold from ‘managing life/recovery’ to ‘managing death/dying process’. In contrast to physicians with ‘backed against the wall’ or ‘peripheral vision’ dispositions, these physicians do not form a judgment about or seek agreement with the patient about the criteria by which to conclude that the suffering is unbearable. Instead, these physicians accept the patient’s assessment, regarding the matter to be too subjective to do otherwise. The question for which they accept responsibility is the competency of the patient who is persistently requesting euthanasia. These physicians are prepared to provide euthanasia to competent patients. They would agree to provide euthanasia for all patients for whom physicians with ‘backed against the wall’ or ‘peripheral vision’ dispositions would provide euthanasia. They also would consider not providing euthanasia in cases in which they are convinced the patient is not competent. They do not experience the level of moral dissonance in agreeing to perform euthanasia common among physicians with ‘back against the wall’ or ‘peripheral vision’ dispositions. Though not often politically active themselves, these physicians hold a disposition toward euthanasia that corresponds most closely with one or more of the parties that have comprised the governing coalition since 1995. Physicians with a ‘bar keeper’ disposition toward euthanasia support efforts to legalize this practice.
4.4 Distribution: Among the Dutch physicians in this study, none have identified themselves with this disposition. The more removed their dispositions are from the ‘bar keeper’ disposition, the more certain they tend to be that the end-of-life management of as many as 20% of current Dutch physicians corresponds most closely with the ‘bar keeper’ disposition. It is my impression that as early as 1973 few (if any) Dutch physicians held a ‘bar keeper’ disposition. By 1984 perhaps a small number of Dutch physicians had concluded that a patient’s ‘quality of life’ is too subjective for physicians to question a patient’s conclusion that their suffering is not bearable and were, thus, prepared to provide euthanasia to patients unless uncertain about their competency. By 1993 it is my impression that the percentage had grown to perhaps 5-10% of Dutch physicians. This percentage seems to have remained constant to the present time.
